cognitive-motor interference in ... - a.t. still university · • controlled - prefrontal cortex...
TRANSCRIPT
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Cognitive-Motor Interference in Persons with Parkinson Disease
Tara L. McIsaac, PhD, PT
Associate Professor of Physical Therapy A.T. Still University
Arizona School of Health Sciences
October 11, 2014 ACRM - Toronto
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Learning Objectives
At the end of this session the participant will be able to: • Discuss the cognitive and motor deficits seen
in Parkinson disease (PD) • Understand the impact of cognitive and motor
deficits in PD on daily activities • Discuss the basis for cognitive-motor
interaction and the possible rationale
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Outline
• Parkinson disease: Background
• Changes in Cognition • Cognitive-Motor Interaction - Theoretical
Frameworks • Evidence of Cognitive-Motor Interference • Rehabilitation for CMI
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Outline
• Parkinson disease: Background
• Changes in Cognition • Cognitive-Motor Interaction - Theoretical
Frameworks • Evidence of Cognitive-Motor Interference • Rehabilitation for CMI
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Parkinson disease • 1 to 1.5 million in U.S.
• 6 to 10 million globally
• 60,000 new cases diagnosed each year in U.S.
• Dopaminergic depletion in basal ganglia, disrupts internal balance in basal ganglia activity (Obeso 2008)
• Clumps of α-synuclein protein, Lewy bodies
• Affects motor and non-motor systems
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Cardinal motor signs of PD • Tremor, rest & postural
– slow frequency (4-6 Hz), supination/pronation
• Rigidity • Akinesia (lack of) / Bradykinesia (slowed) /
Hypokinesia (small) • Postural instability
– retropulsion – festination of steps (also speech & thought) – freezing of gait (FoG)
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Langston 2006, Annals of Neurology
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Goedert et al. 2013, Nature Reviews Neurology
Braak’s 6 Stages of Pathology in PD onset up to 10-15 years before symptoms appear
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Outline
• Parkinson disease: Background
• Changes in Cognition • Cognitive-Motor Interaction - Theoretical
Frameworks • Evidence of Cognitive-Motor Interference • Rehabilitation for CMI
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1. Internal control of attention & action is impaired (Brown & Marsden 1988; Jahanshahi 1995)
2. Self-directed formation of strategies is impaired (Taylor 1986)
3. Set shifting is impaired with dysregulation of top-down and bottom-up attention control (Taylor & Saint-Cyr 1995; Cools 2001, 2009)
4. Planning is impaired with decreased activation of PFC and striatum (Lewis 2003)
Dirnberger and Jahanshahi, J Neuropsychol, 2013. 7(2):193-224.
Executive Dysfunction in PD
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5. Inhibitory control & conflict resolution are impaired, not helped with medication
– Esp. with more complex tasks, generalized across cog and motor domains (Obeso et al 2011)
6. Dual task performance is impaired in motor and cognitive domains (Benecke 1986; Brown 1991,1993,1998)
– 12% of variance in CMI on walking speed explained by reduced EF (Brixton test) (Rochester 2008)
Dirnberger and Jahanshahi, J Neuropsychol, 2013. 7(2):193-224.
Executive Dysfunction in PD
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Executive Dysfunction in PD • 18-36% of newly diagnosed PwPD have cognitive
impairment (Aarsland 2009; Foltynie 2004)
• Prevalence of Mild Cognitive Impairment (MCI) in nondemented PD is 27% (Litvan 2011, 2012)
• Majority of these (~60%) progress to PD with dementia (PDD) over 4 years, compared with 20% of PD with normal cognition (Williams-Gray 2007)
• PD-MCI predicts development of dementia, which can occur in up to 80% in PwPD over the long term (Aarsland 1996, 2003)
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Outline
• Parkinson disease: Background
• Changes in Cognition • Cognitive-Motor Interaction - Theoretical
Frameworks • Evidence of Cognitive-Motor Interference • Rehabilitation for CMI
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Dual Syndrome Hypothesis
Kehagia et al. Neurodegener Dis, 2013. 11(2):79-92.
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Hypothesis differentiates between 2 Broad Syndromes
1. PD-MCI – Tremor-dominant phenotype – Fronto-striatal dysfunction
• Impaired tests of planning, working memory and executive function
• Respond to dopaminergic dosing but also overdosing effects
2. PD-D – Postural Instability/Gait Difficulty (PIGD) phenotype – Posterior cortical and temporal lobe dysfunction
• Early deficits in visuospatial and semantic fluency • Rapid cognitive decline to dementia • Cholinergic treatment may help
Kehagia et al. Neurodegener Dis, 2013. 11(2):79-92.
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1. Attentional control (Stroop, TMT, Tower of London, Verbal Fluency, Design Fluency)
2. Abstract reasoning (Sorting, 20 Questions, Word Context, Proverbs)
• 45% of PwPD had impaired performance on ≥ 1 test
• Impaired group performed significantly worse on attentional control than on abstract reasoning tasks
Kudlicka et al., Dement Geriatr Cogn Disord, 2013. 36(1-2):50-66.
N = 34 PwPD frontal-type deficits on FAB; 59% H&Y stage 1
Cognitive Flexibility represented differently in the 2 aspects of EF
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Models of Executive Function and Attention Control
1. Supervisory Attentional System (SAS) (Norman and Shallice 1986)
2. Multicomponent Model of Working Memory (Baddeley and Hitch 1974)
– Automatic and Controlled processing in both models
• Controlled - Prefrontal cortex (PFC) analogous to ‘central executive’ or SAS – allocating attention
• Automatic - Basal ganglia analogous to ‘contention schedulers’ (Miller and Cohen 2001; Norman and Shallice 1986)
Dirnberger and Jahanshahi, J Neuropsychol, 2013. 7(2):193-224.
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Controlled versus Automatic Processing in PD
Redgrave et al. Nat Rev Neurosci, 2010. 11(11):760-772.
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Kehagia et al. Neurodegener Dis, 2013. 11(2):79-92.
Gradient of dopamine depletion
in PD: Fronto-striatal loops
Dorsal circuits: planning & WM
Ventral circuits:
reward processing and learning
Behavior after
withdrawl of DA in PD
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Outline
• Parkinson disease: Background
• Changes in Cognition • Cognitive-Motor Interaction - Theoretical
Frameworks • Evidence of Cognitive-Motor Interference • Rehabilitation for CMI
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Emerging evidence that: 1) cognition predicts mobility declines & falls and 2) mobility decline & slow gait predict cognitive decline
Montero-Odasso, M., J. Verghese, et al. (2012). J Am Geriatr Soc 60(11): 2127-2136.
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Rochester et al. (2008). Movement Disorders 23(16): 2312-2318. .
Fear of Falling is Largest Predictor of Walking Speed – single and dual task
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Rochester, L., B. Galna, et al. (2014). Neuroscience 265(0): 83-94.
Dual Task Cost to Postural Control of Gait is greater for PwPD
Control n=184; PD n=121
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Rochester, L., B. Galna, et al. (2014). Neuroscience 265(0): 83-94.
Dual task interference on gait and cognitive task of digit span recall
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Spatiotemporal and Variability Measures of Gait are all Impaired by Dual Tasking
Stegemoller et al. (2014). Phys Ther 94(6): 757-766.
PD n=35
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Different control mechanisms for Temporal and Postural aspects of gait
• Stride length and gait speed (temporal aspects) were associated with processing speed measures
• Step width variability (postural aspect) was significantly associated with executive function and attention measures.
• These associations were affected differently by dual-tasking
– only dual task cost to stride length was associated with processing speed
• Slowed overall processing may indicate shared system underlying gait and cognition
Stegemoller et al. (2014). Phys Ther 94(6): 757-766.
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Kelly, V. and A. Shumway-Cook (2014). Exp Brain Res 232(1): 263-271.
For PwPD the ability to change walking as instructed depends on task complexity
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Slower TUG and worse Verbal EF are associated
Verbal Executive Function: • Verbal fluency - Word generation (animals) • Verbal Working Memory – immedediate & delayed recall
Stegemöller et al. (2014). Arch Phys Med Rehab 95(4): 649-655.
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Stegemöller et al. (2014). Arch Phys Med Rehab 95(4): 649-655.
Timed Up and Go performance and Verbal Executive Function performance
predict Quality of Life measures
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• Car accidents 2 to 5 times higher for PwPD • Approach traffic signals more slowly, yet
decelerate later and fail to stop before entering the intersection
• Impaired in navigating curves, steering accuracy, speed adaptation, maintaining constant lane position and lane changing
• Increased reaction times to brake and steer • Greater decline in driving skills with a concurrent
auditory task
Driving and PD
Stolwyk et al. (2006). Movement Disorders 21(12): 2096-2100; Klimkeit et al. (2009). Neurosci Biobehav Rev 33(3): 223-231.
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Cognitive - Motor Dysfunction Impacts Information Processing for Driving
Uc and Rizzo (2008). Curr Neurol Neurosci 8(5): 377-383.
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Hierarchy of Risk Factors for driving in
PD
Crizzle et al. (2012). Neurology 79(20):2067-2074.
ADL = activities of daily living; AVLT = Auditory Verbal Learning Test; BVRT = Benton Visual Retention Task; CDR = Clinical Dementia Rating Scale; DMV = Department of Motor Vehicles; MMSE = Mini-Mental State Examination; ROCT = Rey-Osterrieth Complex Figure Test; HVLT = Hopkins Verbal Learning Test; JOLO = Judgment of Line Orientation; SDMT = Symbol Digit Modalities Test; UFOV = Useful Field of View.
N = 55; H&Y stage 2&3. Rapid Pace Walk • Cutoff ≥6 s • Sensitivity 71% • Specificity 78%
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Dual Task Costs to Arm task and Foot task differ between
PwPD and Controls
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Outline
• Parkinson disease: Background
• Changes in Cognition • Cognitive-Motor Interaction - Theoretical
Frameworks • Evidence of Cognitive-Motor Interference • Rehabilitation for CMI
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Mirelman et al. (2011). J Gerontol A Biol Sci Med Sci 66A(2):234–240.
Dual task performance improvement greater after Virtual Reality training on Treadmill then TT alone (3x/wk x 6 weeks)
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1 month
Mirelman et al. (2011). J Gerontol A Biol Sci Med Sci 66A(2):234–240.
Training improved all aspects of gait, most retained after 1 month
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Training improved cognitive tasks and reduced dual task cost by 56% -
Clinical improvements retained 1 month
Mirelman et al. (2011). J Gerontol A Biol Sci Med Sci 66A(2):234–240.
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Thank you